Provider Demographics
NPI:1457314825
Name:PRESCOTT INTERVENTIONAL RADIOLOGY LLC
Entity Type:Organization
Organization Name:PRESCOTT INTERVENTIONAL RADIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:A
Authorized Official - Last Name:KIRDANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-443-0077
Mailing Address - Street 1:PO BOX 27340
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85061-7340
Mailing Address - Country:US
Mailing Address - Phone:602-943-9200
Mailing Address - Fax:602-216-3000
Practice Address - Street 1:980 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1611
Practice Address - Country:US
Practice Address - Phone:928-443-0077
Practice Address - Fax:928-443-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1Z7128OtherHEALTH NET
60672Medicare ID - Type Unspecified